Urinary System: Quick

Review
 Review of Urinary Anatomy & Physiology

• Located:
– Under back muscles
– Behind peritoneum
• Thus: retroperitoneal
– Below level of lowest ribs
– Right lower than left
– Adrenal gland on top of
kidney
• Medulla
– Contains Pyramids &
Papilla
• Pelvis
– Calyx = division of pelvis
• Pleural = calyces
• Cortex
 Each kidney has 1 million
If total number of functioning nephrons
isless than 20% of normal-
renal replacement therapy needed
Cortical nephrons- 80% to 85%
Juxtamedullary nephrons- 15% to
20%
Glomerulus

Nephrons Bowman’s Capsule

Ureters, Bladder,
Urethra
Bladder capacity 400 - 500 mL
smooth muscle
Urethral sphincter
Micturition
Efflux of urine
Urine Formation 1- Glomerular filtration, 2-
Tubular reabsorption, 3-Tubular
secretion
Amino acids and glucose are
usually filtered at the level of the
glomerulus and reabsorbed
renal glycosuria

Proteinuria (usually low-

molecular weight proteins)
 normal blood flow through
the kidney1000 and 1,300 mL/min

99% of filtrate is
Glomerular reabsorbed
Filtration
ADH (Antidiuretic Hormone)
• Made in hypothalamus; water
conservation hormone
• Stored in posterior pituitary gland
• Acts on renal collecting tubule to regulate
reabsorption or elimination of water
• If blood volume decreases, then ADH is
released & water is reabsorbed by
kidney. Urine output will be lower but
concentration will be increased.
RENIN
• Released by kidneys in response to
decreased blood volume
• Causes angiotensinogen (plasma protein)
to split & produce angiotensin I
• Lungs convert angiotensin I to
angiotensinII
• Angiotensin II stimulates adrenal gland to
release aldosterone & causes an
increase in peripheral vasoconstriction
 kidneys detect a decrease in
the oxygen tension-release
ERYTHROPOIETIN.
Regulation of Red
Blood Cell
Production
 kidneys are responsible for
the final conversion of
inactive vitamin D to its active
Vitamin D form, 1,25
Synthesis dihydroxycholecalciferol.
 kidneys produce
prostaglandin E and
prostacyclin, which have a
Secretion of vasodilatory effect and are
Prostaglandins important in maintaining renal
blood flow.
 kidneys eliminate the body’s
metabolic waste products.
The major waste product of
protein metabolism: urea, of
Excretion of
Waste Products (about 25 to 30 g)
Other wastes: creatinine,
phosphates, and sulfates, uric
acid, drug metabolites
 filling and emptying of the
bladder are mediated by
coordinated sympathetic and
parasympathetic nervous system
parasympathetic pelvic nerves at
Urine Storage the level of S1 through S4
150 to 200 mL- sensation of
fullness
300 mL to 500 mL - strong
desired to void
 Initiation of voiding - efferent
pelvic nerve, which originates in
the S1 to S4 area
micturition- mediated by
Bladder muscarinic an cholinergic
Emptying receptors within the detrusor
pressure during micturition 20
40 cm H2O
 Volume of urine also controlled by glomerular filtration rate

• Unique arrangment of blood vessels

– Afferent arteriole -----to----capillary bed-----to----efferent arteriole -----to---
--capillary bed ----to---- veins
• First capillary bed = glomerular capillaries
• Second capillary bed = peritubular capillaries
• Purpose of this = to control the pressure in the glomerular capillaries &
consequently the glomerular filtration pressure
• 3 factors control this:
• (1) autoregulation
• Local feedback from muscle tension in afferent arteriole
• Local feedback from DCT at JGA
• Mediated via endothelial
secretions of glomerular capillaries
• (2) sympathetic nervous system
• (3) renin
• B = increase fluid volume; overhydration; high output heart
failure
• C = kidney pathology
• D = hypertension; arteriolar spasm
– Hormones help control the volume of urine via fluid &
electrolyte balance
• The concentration factor essentially deals with urine volume
– Usually more the volume = more the dilution [a direct
proportion]
1. Aldosterone
» From adrenal cortex
» Works on distal convoluted tubule
» Causes H2O & Na+ retention
2. Atrial natriuretic hormone(ANH)
» From atrial wall of heart
» Works on distal convoluted tubule
» Works in opposition to aldosterone
» Causes H2O & Na+ loss
3. Antidiuretic hormone
» From posterior pituitary
» Works on collecting tubules
» Causes reabsorption of H2O (Na+ goes with it)
MANAGEMENT OF PATIENTS
WITH URINARY
DISTURBANCES
NCM 103
URINARY INCONTINENCE
URINARY INCONTINENCE
• involuntary loss of urine from the bladder
Types of Urinary Incontinence
Stress Urge
incontinence incontinence

Functional Iatrogenic
incontinence incontinence

Mixed urinary
incontinence
Stress incontinence
• involuntary loss of urine through an intact urethra as a result
of sneezing, coughing, or changing position
• predominantly affects women who have had vaginal
deliveries
• In men, is often experienced after a radical prostatectomy
Urge incontinence
• involuntary loss of urine associated with a strong urge to void
that cannot be suppressed.
• The patient is aware of the need to void but is unable to
reach a toilet in time
• Precipitating factor: uninhibited detrusor contraction
• can occur in a patient with neurologic dysfunction that
impairs inhibition of bladder contraction
Functional incontinence
• instances in which lower urinary tract function is intact but
other factors, such as severe cognitive impairment (eg,
Alzheimer’s dementia), make it difficult for the patient to
identify the need to void or physical impairments make it
difficult or impossible for the patient to reach the toilet in
time for voiding
Iatrogenic incontinence
• refers to the involuntary loss of urine due to extrinsic medical
factors, predominantly medications.
• Example: alpha-adrenergic agents
Mixed urinary incontinence
• encompasses several types of urinary incontinence
• involuntary leakage associated with urgency and also with
exertion, effort, sneezing, or coughing
Assessment and Diagnostic Findings
• History
• Urodynamic tests
• Urinalysis
• Urine culture
Medical Management
• Behavioral Therapy
• FLUID MANAGEMENT

• daily fluid intake of approximately 50 to 60

ounces (1500 to 1600 mL), taken as small
increments between breakfast and the evening
meal
• Fluids containing caffeine, carbonation, alcohol,
or artificial sweetener should be avoided
Medical Management
• STANDARDIZED VOIDING FREQUENCY
• Timed voiding
• involves establishing a set voiding frequency (such as every 2
hours if incontinent episodes tend to occur 2 or more hours after
voiding).
• The individual chooses to “void by the clock” at the given interval
while awake, rather than wait until a voiding urge occurs.
• Prompted voiding
• timed voiding that is carried out by staff or family members when
the individual has cognitive difficulties
Medical Management
• STANDARDIZED VOIDING FREQUENCY
• Habit retraining
• timed voiding at an interval that is more frequent than the individual would usually
choose.
• helps to restore the sensation of the need to void in individuals who are experiencing
diminished sensation of bladder filling due to various medical conditions
• Bladder retraining
• Incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit
voiding, or leaking urine
• When the first timing interval is easily reached on a consistent basis without urinary
urgency or incontinence, a new voiding interval, usually 10 to 15 minutes beyond the last,
is established
Medical Management
• PELVIC MUSCLE EXERCISE (PME)
• Also known as Kegel exercises
• aims to strengthen the voluntary muscles that assist in bladder and
bowel continence in both men and women
• Biofeedback-assisted PME uses either electromyography or
manometry to help the individual identify the pelvic muscles as he
or she attempts to learn which muscle group is involved when
performing PME
• PME involves gently tightening the same muscles used to stop flatus
or the stream of urine for 5- to 10-second increments, followed by
10-second resting phases.
Medical Management
• VAGINAL CONE RETENTION EXERCISES
• an adjunct to the Kegel exercises
• Vaginal cones of varying weight are inserted
intravaginally twice a day
• The patient tries to retain the cone for 15 minutes by
contracting the pelvic muscles.
Medical Management
• TRANSVAGINAL OR TRANSRECTAL ELECTRICAL STIMULATION
• electrical stimulation is known to elicit a passive contraction of the pelvic
floor musculature, thus re-educating these muscles to provide enhanced
levels of continence
• often used with biofeedback-assisted pelvic muscle exercise training and
voiding schedules.
Medical Management
NEUROMODULATION
• Neuromodulation via transvaginal or transrectal
nerve stimulation of the pelvic floor inhibits
detrusor overactivity and hypersensory
• bladder signals and strengthens weak sphincter
muscles
Medical Management
• Pharmacologic Therapy
• Anticholinergic agents
• Inhibit bladder contraction
• first-line medication for urge incontinence
• tricyclic antidepressants
• (eg, amitriptyline [Endep], amoxapine [Asendin])
• can also decrease bladder contractions as well as increase
• bladder neck resistance
• Pseudoephedrine sulfate (Sudafed)
• acts on alpha-adrenergic receptors, causing urinary retention
• may be used to treat stress incontinence;
• needs to be used with caution in men with prostatic hyperplasia.
• Hormone therapy
• (eg, estrogen)
Surgical Management
• Anterior vaginal repair, retropubic suspension, or needle
suspension to reposition the urethra
• Women with stress incontinence may undergo.
• Periurethral bulking
• is a semipermanent procedure in which small amounts of artificial collagen
are placed within the walls of the urethra to enhance the closing pressure
of the urethra
• Artificial urinary sphincter
• can be used to close the urethra and promote continence
• Transurethral resection of the prostate
• For men with overflow and stress incontinence
Nursing Management
• For behavioral therapy to be effective, the nurse must provide
support and encouragement
• Teach patient to develop and use a log or diary to record timing of
pelvic floor muscle exercises, frequency of voiding, any changes in
bladder function, and any episodes of incontinence
• Maintain skin integrity
• Promote measures to maintain fluid and electrolyte imbalance
• Ensure adequate nutrition
• Provide an environment that promotes easy access to bathroom,
urinal, or bedpan
• Promote client and family coping
NEUROGENIC BLADDER
NEUROGENIC BLADDER
• a dysfunction that results from a lesion of the nervous
system and leads to urinary incontinence.
• It may be caused by spinal cord injury, spinal tumor,
herniated vertebral disk, multiple sclerosis, congenital
disorders (spina bifida or myelomeningocele), infection, or
complications of diabetes mellitus
Pathophysiology
• The two types of neurogenic bladder:
• spastic (or reflex) bladder
• Empties on reflex, with minimal or no controlling influence to regulate its
activity.
• Caused by a lower motor neuron lesion, commonly resulting from trauma
• flaccid bladder
• Caused by any spinal cord lesion above the voiding reflex arc (upper motor
neuron lesion)
• The result is a loss of conscious sensation and cerebral motor control.
Assessment and Diagnostic Findings
• Clinical Manifestations:
• Residual urine detected on bladder catheterization
• Some degree of incontinence
• Bladder distention
• Restlessness
• Labs
• Cystography – detects vesicoureteral reflex
• Urethrography- detects urethral complications
• BUN, s. crea, creatinine clearance elevated
• Postvoid catheterization – reveals residual urine more than 50 ml
Complications
• UTI
• urolithiasis
• vesicoureteral reflux
• hydronephrosis
Medical Management
• Continuous, intermittent or self-catheterization
• Diet low in calcium(to prevent calculi)
• Mobility and ambulation
• Liberal fluid intake
• Bladder retraining
• Parasympathomimetic medications
• Bethanechol (Urecholine) - increase the contraction of the detrusor muscle.
• Surgery to correct bladder neck contractures
Nursing Management
• Perform intermittent catheterization usually every 4-6 hours
• Instruct client and family on self-catheterization
• Instruct the client on the proper way to apply and use an
external collecting device (Eg. Condom cath)
• Provide bladder training
• Prevent calculi
RENAL DISORDERS
NEPHROSCLEROSIS
• hardening of renal
arteries due to
prolonged
hypertension or DM
NEPHROSCLEROSIS
TWO forms
• Malignant
• occurs in young adults (2x in men than women)
• associated with hypertension
• Benign
• occurs in older adults
• Associated with atherosclerosis and hypertension
Assessment findings
• Hematocrit
• Creatinine
•Serum potassium
•Serum calcium
•Lipid panel
•Blood glucose
•Urinalysis
•Urinary albumin-to-creatinine ratio
Medical Management
• ACE inhibitors
• treat underlying cause
ACUTE NEPHRITIC SYNDROME
• glomerular inflammation
• causing passage of protein in urine (2
to 3 g per day)
• a combination of protein range
proteinuria
Clinical Manifestations
• azotemia
• microscopic hematuria
• edema
• proteinuria
• cola-colored urine
Clinical Manifestations
• Severe cases
•Headache
• malaise
• flank pain
• engorged neck veins
• pulmonary edema and cardiomegaly
Assessment and Diagnostic Findings
• enlargement of kidneys
• elevated IgA
• biopsy
Complications
• hypertensive encephalopathy
• rapid decline leads to ESRD
• Prognosis : excellent
Nursing Management
• intake and output monitoring
• patient
education of the disease and
treatment
CHRONIC
GLOMERULONEPHRITIS
• repeatedoccurrence of acute nephritic
syndrome, nephrosclerosis, glomerular
sclerosis
Clinical manifestations
• poorly nourished
• yellow-gray pigmentation of the skin
• Peripheral and periorbital edema
• BP maybe normal or elevated
• cardiomegaly may be present
• crackles and rale
• Peripheral neuropathy and diminished DTR
Assessment and Diagnostic
findings
• urine sg 1.010
• presence of urinary casts
• GFR of 50 ml/min
• chest x-ray : cardiac enlargement
• MRI : decreased size of of renal cortex
Medical Management
• diuretic medications
• Sodium and water restrictions
• weight monitoring
• early dialysis
Nursing Management
• relieve anxiety
• provide emotional support
• self-care needs
•Follow-up evaluations
NEPHROTIC SYNDROME
•A renal failure manifested by massive
proteinuria, hypoalbuminemia, high
serum cholesterol and hyperlipidemia
• any condition that damages the capillary
membrane and results in increased
glomerular permeability to plasma protein
Clinical manifestations
• presence of edema (soft and pitting)
• irritability
• headache
• malaise
Assessment and Diagnostic
findings
• proteinuria (3.5 g/day)
• presence of WBC in urine
• epithelial casts in urine
• renal biopsy
Medical Management
• treat underlying conditions
• prevention of CKD
• prescribing diuretics
• ACE inhibitors
• antilipidemic agents
POLYCYSTIC KIDNEY
DISEASE
• presence of cysts in
the kidney
• may be inherited
• Autosomal dominant /
recessive PKD
Clinical manifestations
• increasing size of kidneys
•Hematuria
• polyuria
• hypertension
• renal calculi
• fullness and flank pain
ACUTE RENAL FAILURE
• acute renal failure (ARF)
• rapid loss of renal function due to damage
• potentially life-threatening
• increase in serum creatinine of 50%
• may have oliguria, nonoliguria, or anuria
ACUTE RENAL FAILURE
• CATEGORIES
• Prerenal
• Intrarenal
• Postrenal
Clinical manifestations
• lethargic and appear critically ill
• dry mucous membranes
• headache, drowsiness
• muscle twitching and seizures
Assessment and Diagnostic findings
Assessment and diagnostic
findings
•Scanty to normal volume
• urine specific gravity is low
• Inability to concentrate urine is the earliest
sign of kidney damage
• anatomic changes in kidney in CT scan or
MRI
•Progressive metabolic acidosis
Prevention
• provide adequate hydration
• prevent and treat shock promptly
• treat hypotension promptly
• assess renal function continuously
• treat infections promptly
• treat sepsis
• Prevent toxic drug effecs
Medical Management
• hemodialysis / peritoneal dialysis / CRRT
• treatment of hyperkalemia (usage of Kayexalate)
• proper ventilation
• phosphate-binding agents
• Nutritional therapy
•
Nursing Management
• monitoring fluid and electrolyte imbalance
• reducing metabolic rate
• promoting pulmonary function
• preventing infection
• providing skin care
• provide psychosocial support
INFECTIONS OF THE
URINARY TRACT
URINARY TRACT INFECTIONS
• caused by pathogenic microorganisms
• classified either lower UTI and upper UTI
• second most common infection in the body
• cases common in women (1 out of 5)
• urinary tract is the most common site for
nosocomial infections
UTIs
•Lower UTI
• cystitis
• prostatitis
• bacterial urethritis
• Upper UTI
• pyelonephritis
LOWER UTI: Pathophysiology
• Bacterial invasion of the urinary tract
• Deactivation of glycosaminoglycan (GAG)
• absence of normal bacterial flora of the
vagina and urethra
• absence if immunoglobulin A (IgA)
LOWER UTI: Pathophysiology
• Reflux
• urethrovesical reflux
• ureterovesical reflux
LOWER UTI: Pathophysiology
• bacteriuria
• more than 105 colonies of bacteria per ml of
urine
• Routes of infections
• transurethral route
• bloodstream
• fistula
Clinical manifestations
• 50% with bateriuria do not manifest symptoms
• s/s of uncomplicated lower UTI
• burning on urination
• increased frequency
• incontinence
• nocturia
• Suprapubic or pelvic pain
• Complicated UTI
• Sepsis or shock
Assessment and diagnostic findings
• Urine cultures
• Groups of patients to have urine culture
when bacteriuria is present
• all children all men DM patients
• recent instrumentation and hospitalized
• pregnant women postmenopausal women
• sexually active or with new sexual partners
•3 or more recent UTI in a year
Assessment and diagnostic findings
• pyuria (WBC 4 /hpf)
• CT scan for abscesses
• ultrasound for obstruction
•Cystourethroscopy
Medical management
Nursing Management
• relieving pain
• increase fluid intake
• remove urinary tract irritants
• encourage frequent voiding
• Monitoring potential complications
• use strict aseptic technique when inserting catheters
• securing catheters
• maintaining a closed system
• perineal care
• teaching self-care
UPPER UTI
• Pyelonephritis
• acutely ill with fever and chills
• leukocystosis
• flank pain
• nausea and vomiting
PYELONEPHRITIS: Assessment
• CT scan
• IV pyelogram
• radionuclide imaging
• urine culture and sensitivity testst
PYELONEPHRITIS: Medical
management
• medications for UTI (table)
• hydration with oral or parenteral fluids
PYELONEPHRITIS: Nursing
management
• increase OFI
• VS q4
• medications as ordered
• emptying bladder frequently
• proper perineal hygiene
• Adherence to treatment regimen